Maria; I know of no periods in which ready-to-use supplementary food have been used for longer than 5 months. This was in Niger. Theoretically I can't see why eating the same thing every day for a year or two raises 'grave concerns', most people in the world do it. In the case of a supplementary peanut spread, there is plenty of room in the diet for other foods too. Mark Manary

HETN; Your concerns are listed as follows * The high level of protein in Plumpy'nut is not appropriate. The protein content is 15% in Plumpy'Nut. This compares to 13% for rice and 25% for soy. It is not a high protein food * The milk powder base can cause diarrhoea in the many who have lactase deficiency. Absolutely wrong, we published a paper on this about 10 years in malnourished children. The fact is the diarrhea is not seen in Africans with lactose. Milk is a good food for young children across the world, even in Africa. * The high levels of oil and refined sugar (30%) are inappropriate and would make such a product unacceptable for children in the UK. Certain peanut butter has this much oil. Children eat candy around the world too. * The high cost of the components makes it unaffordable, and therefore unsustainable in the African context, without donor funding. It costs a lot because it has expensive ingredients, but that does not mean it is a poor food. The product HETN supports is something that would be described as a poor complementary food by the WHO

Considering the risk that has been shown in giving high levels of iron to children in malaria endemic areas, would not there be a risk in giving doses of plumpy doz higher than the recommended 46g per day?

Please remember that LNS is a broad category which does include Plumpy Nut for treatment of severely malnourished children. Most of the LNS products that are being tested and used for prevention of malnutrition are not Plumpy Nut.

Thank you all!

Hi Maria Unicef in Somalia is distributing Plumpy'Doz to children over a period of 8 months as a supplementary food to prevent malnutrition. See the article below & it may be worth contacting them for more information on the programme. [url]http://www.unicef.org/media/media_46991.html[/url]

Dear HETN Thanks for raising some important concerns over the long-term use of Plumpy'Nut and Plumpy'Doz. I think the crucial point from this discussion is that, when used in the medium to longer-term to prevent malnutrition, these products are used as supplements to an existing diet and are appropriate in specific contexts for clearly defined vulnerable children.

From Basil Kransdorff: I wonder how many people out there who are responsible for funding and distributing Plumynut would consider giving their child a huge dose of sugar daily. I know - if we do this in our own household - our son would trash the place. As a result we have banned for our son all products with high levels of sugar in our own home. I ask the question - just how much of what is viewed as recovery when a malnourished child eats Plumpynut is nothing more than a sugar drug induced high similar to what we see in our own kids when drinking a sugar drink. Perhaps we should look at the Plumpynut clinical evidence that I am told is available to see just how the micronutrient status improves or maybe gets worse for the kids eating Plumpynut. Lets compare the micronutrient status of kids eating Plumpynut to kids eating other commonly used products like CSB that are distributed as nutrition to kids in malnourished enviroments. I am sure the results will be illuminating. The known science says - - inorganic nutrients used to fortify products just cannot bring back the kids to nutrient repleteness. Because children have a daily requirement, all shortfalls will compound themselves making the children more nutrient defecient. The argumenet that a little is better than nothing is therefore not appropriate when trying to address the nutrient needs of children. Has anybody wonder why products like CSB and Plumpynut are not sold and eaten in the USA and the European Common Market as a nutritional suppliment. Certainly I know the answer in the case of Plumynut. Plumpynut would fall foul of the UK advertising laws which bans advertising of food products with high level of sugar and fat to children. The clinical evidence based on outcome based science will certainly clarify the debate. Is the 'waking up' of malnourished children in Africa who are given donor funded Plumpynut as a result of a sugar drug induced high or is it as a result of the children being brought back into nutrient repleteness. I believe the cause of the concern that has been raised is around a flaw in the logic of the way and for whom the formulation Plumpynut has been created. I am told by Andre Briend the inventor of Plumpynut (now employed by the WHO) that the Plumynut food product is safe because it has been based on the well tested and excellent F100 formulation. As a therapeutic food used to rescue a severely malnourished children, he tells me, Plumpynut should only be used for about 2 weeks and therefore concerns around the high levels of sugar and fat are not appropriate. For me, this explanation could be acceptable. Using Plumpynut with its high levels (30% sugar) for a very short period would be similar to a "sugar drip" used for injured traumatized patients that saved many lives of wounded soldiers in the Vietnam War. What does not make sense is to use such a formulation as a tool to address malnutrition over several months. Copying the formulation approach of F100 formulation and using the same approach in a food that is specified and marketed (using donor funding) as a "miracle food supplement" that will address malnutrition in young children over longer periods of more than two weeks does not make logical sense. F100 is used in a therapeutic emergency by medically trained personal over a short period. Using Plumpynut for long periods is rather like putting a malnourished child onto a sugar drip for several months. Plumpynut is not an appropriate formulation for a community managed food approach to address the nutritional condition of malnourished children in a community based environment if the objective is to ensure the children come back to nutrient repleteness. The high levels of sugar and fat for long periods are inappropriate as are the milk solids which could cause diarrhea (lactose intolerance). The selection of micro nutrient form has already been articulated by HETN. The nutrient form specified in Plumpynut cannot address the daily nutrient requirements of any child never mind one that is severally malnourished. The known science says - this is impossible because of known nutrient clashes and low evidence of bio-availability. What amazes me the most about the whole Plumpynut debate is the deafening silence from many professionals (nutritionists). I have even heard arguments given by a few that the high levels of sugar for a product for Africa is okay because malnourished kids in Africa are different to kids in Europe. There is even debate about using Plumpynut in HIV and TB programs. I shudder at the consequence with these high levels of sugar feeding thrush. Basil Kransdorff

Thank you very much for shading some light. From your urgument on the plumpy- nut issues. I agree that its a miracle food for a malnourished child; I have had experience using it during the post election violence in Kenya and the children improved realy fast and even some mothers didn't want their children weaned from the programme. But I have not use it for a long time. From what i have read in this forum I would not recomemnt plumpy-nut to be use for a long time .

Dear Basil, I think it is fair to point out that there are many products and formulations used in the dietetic management of infants and young children in the western world - so use of therapeutic formulations - your RUTF equivalents as it were - is very well established. I've worked and used them first hand as a paediatric dietitian in UK and in Ireland. Some are high in fat, some high in sugar, some have completely artificial make-ups that do not resemble food as we know it but are indicated and appropriate for conditions and treatment. Just like a child admitted to intensive care may need 70% oxygen, so they may need some alternative dietetic interventions to support them. This does not preclude them breathing air when they go home, any more that children won't eat and rely on normal decent food. The real challenge in this debate, I think, is dovetailing therapeutic interventions for malnutrition treatment with optimal infant and young child feeding, and developing a spectrum of feeding options and criteria for use.

Plumpy nut from nutriset is a great product to address malnutrition in places where you have nothing or very little to offer to save lives of children. It did amazingly good in many settings and it is important to note the objective why this formulation was produced in the first place. There is every arguement going in favour of conducting some meaningful operational research on this product but it is not appropriate to call it as "sugar drip" or developing lactose intolerance while it is not the case in general. The effects of giving Plumpy nut to children under five for a longer periods of time is still not clear but at the same time there are experiances rangeing from 5 months - 8 months period with no untoward effect noticed in children and this is mainly in africa.